Canada / Portugal Agreement Applying for a Portuguese Old Age and/or Disability Benefit Here is some important information you need to consider when completing your application. Please ensure you sign the application. If you are signing with a mark, (for example: “X”) the signature of a witness is required. Your application must be supported by documentation. Please submit the documents requested. Failure to complete the application and provide the requested documentation may result in delays in processing your application. Where original documents are specifically requested, originals must be submitted with your application. You should keep a certified true copy of any originals you send us for your records. Some countries require original documentation which will not be returned to you. You may submit the original or a photocopy that is certified as true for any of the documents where originals are not required. It is better to send certified copies of documents rather than originals. If you choose to send original documents, send them by registered mail. We will return the original documents to you. We can only accept a photocopy of an original document if it is legible and if it is a certified true copy of the original. Our staff at any Service Canada centre will photocopy your documents and certify them free of charge. If you cannot visit a Service Canada Centre, you can ask one of the following people to certify your photocopy: Accountant; Chief of First Nations Band; Employee of a Service Canada Centre acting in an official capacity; Funeral Director; Justice of the Peace; Lawyer, Magistrate, Notary; Manager of Financial Institution; Medical and Health Practitioners: Chiropractor, Dentist, Doctor, Pharmacist, Psychologist, Nurse Practitioner, Registered Nurse; Member of Parliament or their staff; Member of Provincial Legislature or their staff; Minister of Religion; Municipal Clerk; Official of a federal government department or provincial government department, or one of its agencies; Official of an Embassy, Consulate or High Commission; Officials of a country with which Canada has a reciprocal social security agreement; Police Officer; Postmaster; Professional Engineer; Social Worker; Teacher. People who certify photocopies must compare the original document to the photocopy, state their official position or title, sign and print their name, give their telephone number and indicate the date they certified the document. They must also write the following statement on the photocopy: This photocopy is a true copy of the original document which has not been altered in any way. If a document has information on both sides, both sides must be copied and certified. You cannot certify photocopies of your own documents, and you cannot ask a relative to do it for you. Return your completed application, forms and supporting documents to: International Operations Service Canada P.O. Box 2710 Station Main Edmonton, AB T5J 2G4 CANADA Disclaimer: This application form has been developed by external sources in cooperation with Employment and Social Development Canada. The content and language contained in the form respond to the legislative needs of those external sources. REQUERIMENTO DE PRESTACOES DE INVALIDEZ OU VELHICE DA SEGURANCA SOCIAL PORTUGUESA AO ABRIGO DO ACORDO ENTRE PORTUGAL E o CANADA APPLICATION,FOR PORTUGUESE DISABILITY OR OLD AGE BENEFITS UNDER THE PORTUGAL CANADA SOCIAL SECURITY AGREEMENT - D ~ M A N D EDE PRESTATIONS PORTUGAISES D'INVALIDIT~OU DE VIEILLESSE AUX TERMES DE L'ACCORD DE S ~ C U R I TSOCIALE ~ ENTRE LE PORTUGAL ET LE CANADA Assinalar a prestaqifo p t e n d i d a Check the benefit for which y o u wish t o apply Cochez l a prestation demand& Pensgo d e invalidez Disability pension Pension &invalidit6 Pensifo de velhice OM a g e pmsion Pension d e vieillesse PREENCHER EM LETRA DE MPRENSA I PLEASE PRINT / &CRIVEZEN LETTRES MOUL~~ES INFORMAC~ES SOBRE 0 SEGURADO I INFORMATION CONCERNING THE INSURED PERSON 1 R~NSEIGNE MENTS CONCERNANTL'ASSURB 1.I. Nomes pr6prios / F i t names / Mnoms Apelidos /Surnames / Noms & famille 1. I ~ i d a d k& s origan pormguesa devem indicar 0s nomes pr6prios e apelidos tal m o mhaam an documento oficial portuguEs (biiete del identidade ou passaporte) Citizens of Portuguese origin must indicate their first names and surnames as shown on an official Portuguese document (identity card or passport) Les citoyens d'origine portugaise doivent indiqua leurs prtnoms et noms de famille tels qu'indiqds sur un document officiel portugais (carte d'i&ntid ou passeport) I. 1.2. N h e r o da Seguranqa Social Portuguesa Portuguese Social Security Number Numtro d'assurance sociale du Portugal N h e r o da Seguranqa Social no Canad4 Canadian Social Security Number Numtro d'assurance rociale du Canada u 1111111111 N h m fiscal de contribuinte em Portugal (se possuir cartHo & contribuinte,juntar fotoc6pia) Taxpayer number in Portugal (if you have taxpaycr card. please enclose a photocopy) N h e r o fiscal au Portugal (sivous possedk une cartc f d e , veuillez inclurc une photocopie) u 1.3. Enderqo Address Adresse 1A. 1.5. N h e r o . ma.apart.. caixa postal Number. Street, Apt, P.O. Box Numtro. rue app., case postale Cidade ou localidade City or Town Ville ou village Provhcia ou terridrio Province or territory Province ou tcrritoire C6digo postal Postal Code Code postal Nome do pai Father's name Nom du #re Nome da mHe Mother's name Nom de la m&e Nomes pr6~rios/ Fist Names / PrCnoms Dam de nascimento Date of birth Date de naissance Lugar de nascimento Place of birth Lieu de naissance Dia Day Jour Mis Ano Month Year Mois Ann& I/- Apelidos / Surnames / Noms de Famille Cidade ou localidade City or town Ville ou village Distrito ou provincia District or province District au province Freguesia Parish Puoisre PlIs Country Pays ' - 1- 1.6. Estado civil (marcar V) Marital status (check h e appropriate box) h a t civil (cochez la case appropride) Solteiro(a) Single Ctlibataire 1.7. Casado(a) Mamed Mariee) ViGvo(a) Widower(widow) Veuf(veuvc) Divorciado(a) Divorced DivorcC(e) Separado(a) C) Separated Separd(e) ProfissXo exercida nos w f anos anteriores ao requerimento Occupation held in the last three years prior to the claim Profession exercde dans les wois dernikres ann&s prCcedant la demande Se, ap6s o requerimento continuar a exercer protissiio. qua1 ? After having made the claim do you continue working ? Spkify: Est-cc que vous continue2 h exercer m e profession aprL avoir present6 la demande? Indiquez laquelle. 1.8. Caixas de PrevidEncia ou Centros Regionais de Seguranp Social para onde descontou em Portugal Social security Funds or Regional Centres to which contributions were made in Portugal Caisses ou Centres RCgionaux de Stkuritt Social ob vous avez cotis6 au Portugal Denominaqiio /Name / Nom 1.9. Datas / Dues I Dates NJmem de Seguranqa Social Social Security number Numtro d'assurance sociale A~CITOIA De/From/De AAAA- Ad- / IJ- / 22- Recebe pens50 de acidente de hpabalhoou doenqa profissional ? Are you receiving a work-related pension as the result of an accident or occupational disease ? Recevez-vous une pension suite B un accident du travail ou h m e maladie professionnelle ? NHo /No / Non Sim/Yes/Oui Valor mensal da pensb Monthly amount of pension Montant masuel de la pension InstituiqHo devedora Paying institution Institution &bitrice 1.10. Recebeu ou vai receba alguma indemnizaqIo an consequhcia de acidente da respawabilidade de taceiros 7 Have you received or will you receive compensation as a result of an accident caused by a third party ? Avez-vous dtjh y u ou allez vous recevoir une prestation en raison d'un accident de la rcsponsabilitCd'un tiers ? Sim /Yes / Oui Valor / Amount / Montant NHo /No / Non Global .Lump-sum payment Global Mensal Monthly Amouns Mensuel 1.11. Trabalhou noutros paises e wteve al abrangido pela seguraqa social ? Have you worked in other countries where you had social security coverage 7 Avez-vous travail16 d m un autre pays ob vous Ctiez assujetti h la Sccuritk sociale ? sim/Ycs/Oui NH./No/Non Datas / Dates / Dates Pds / Coun~ry/Pays De/From/De A~CITOIA 2 3 2 2 2 - 2 3 - J J - 2. 2.1. INFORMAC~ESSOBRE 0 CONJUGE /INFORMATION CONCERNING THE SPOUSE I RENSEXGNEMENTS C O N ~ R NANT LE CONJOMT Nome. pr6prios / First names / RbKlms Apelidos / Surnames/ Noms & famille 1 0 s cidadaos de origan portuguua devan indicu os nomes prdprios e apelidos tal como constam an documentooficial portugu6.s de idcntidadc ou psssaporte) Citizens of Portuguese origin must indicate thciu first names and surnames as shorn on an official Pomguac document (identity card or p=spon) Les citoyens d'origine portugaise doivent indiquer l e w prborns ct noms de famille ~ l qu'indiqub s sur un document officiel p ~ w g a i s (carte d'identid ou passeport) 2.2 Da~adenrscimento Dak of birth Date de n a i s s ~ c e Data de casamento Date of marriage Date de mariage Dia Day Jour Dia Day Jour Mis Ano Month Year Mois Ann& I/- I RofssBo Occupation Profession M6s Ano Month Year Mois Ann& 22- ; : 23. 0 dnjuge exem urn actividade s a l h d a 7 I Is your spouse a salpied anployee ? Votre mnpint urnce-1-il(elle) m e activid s a k i & 7 Valor do salalkio mensal Amount of monthly salary Montant du salaire mensue1 Non Oui Non DcmmbqaO da uuidade patronal Employen'name md addms Nom et adresse & l'employeur 2A. 0 chjuge exem uma rctividak nib Mlariada 7 Is your spouse self-employed 7 Votre conjoint exerce-t-il (elle) un emploi autonome 7 Valor m a d das r e t r i i Monthly income from r e l f u n p l o y m ~ Revenu mensue1 & cet anploi Ramo de actividade Type of activity Geme d'activid 25. Chixu & Revidioei. ou c a m s Regionais & Segunnp Social para on& o odnjuge desumta ou dscmtou So& Seapity Funds a R e g i d C a m s to which your rpouse c o n t r i ~ o r h u conaibutsd Cakes ou Ce;urcz RCgiauux & S&uritC Socide oh votre conjoint cotise ou a cotisC 2.6. 0 dnjuge ~cccbeou n q m u qudquer pensb 7 Does your spouse receive or has he or she applied f a a p i o n ? Votre conjoint repit-il (elle) une pension ou a-t-il (elle) demand6 m e pension 7 Vllormensaldapentllo Monthly mount of pension Montant macucl de la pension 2.7. Ndmerr, & S c g m q a Social Social SecuritynMlbr Num&u d'rssurtnce d Sim rJYa Oui e UE' Non I n s t i t u w devedon Paying institution Institution dtbimce Outm r e d h m m s do ehjuge / Spwse'r o t h a income/ Autns revenus de votre ampint Valor m w a l Monthly mount Monunt mensucl :: Oui Nahlrezr dos rendimentos Type of income Genre & revmu I 3. RENDIMENTOS DO SECURADO I INCOME OF THE INSURED PERSON I REVENU DE L'ASSURB I P e n s k 1 Pensions 1 Pensions I 3.1. I a Valores mensais Monthly amounts Montants mensuels Instituifies devedoras Paying institutions Institutions dtbinices 3.2. Montane dos salMos recebidos pel0 uercicio & uma actividade profusional salariada Income from salaried employment Revmu d'un emploi salurit Dmonhqiio e enduqo dar mtidades p a ~ ~ ~ n a i s Employers' names and addresses Noms et dresses des employem Salhio mensal Monthly salary Sdaire mencuel 33. Rmdimmtoa Uquidos pelo uadci de actividrde como comerciank Net income from h e openlion of a business Revenu net provenant de I'opCrarion d'un cmmmeroe Redimento mmsal pelo exackio da actividadc Monthly income from business Revmu mmsuel proverwt du commerce I 3.4. ' 4. Lucre d& e x p l o ~ Year's profit Profit annuel ~ Rmdimentns wmuns do regun& e do h j u g e Joint income of the insured person md spouse Revenu commun & I'assurt et du conjoint V a l m mcnsais Monthly amount Montant mensue1 Natureza dos mdimmtos Type of income Garnderevaru INFORMAC~ESSOBRE 0 REQUERENTE COM NECESSIDADE DE ASSISTI~ICIAPERMANENTE DE TERCEIRA PESSOA CLAIMANT NEEDING THE CONSTANT ASSISTANCE OF ANOTHER PERSON RENSElGNEMENTS CONCERNANT LE REQU$WT QUI A B ~ O I NDE L'ASSISTANCE CONSTANTE D'UNE TIERCE PERSONNE I d a t i f i i / Idnrtifiiui011/Identi6catim Identifca@o da tnrein pcssoa quc pram rsrirtinci Idenrification of the persun who assists the claimant Idenficetion de la tierce parorme qui assine le requ&ant Enderep complcto / Complete A d d m / M m s e Considera-se que uma pcrsoa tun n d d a d e de assistincia pennancntc de urn urcein quando n b possa praticu com auconomia or wtns indispcdveis A srtisfaqiiodar rucessiddcshumanas k i c m (cuidados& higimepessoal. [email protected]@o). DEVE SER CERTLFICA, DO A T R A V J DE ~ RELAT~RIOM ~ D I C O . The person concerned is deuned to nced constant usisterm of mother person whar the adinaty h v i t i e s of everyday life a n not be perfmmed by him/hasclf (puwnal hygiene.feeding. movement). MEDICAL REPORT MUST BE PRESENTED. Or considbe qu'une patorme r W n i & r~irrurce canstante d'une tiace p a o n n e si elle ne peut prr s'occuper d'elle mime ( h y g i h ~ l l e. l i. m d o n . locomotion). ON DOIT P R ~ E N T E RUN RAPPORT M ~ ~ I C A L . - - - Pelo present&solicito as prestq8u de InvalidezIVelhiceda Seguran~aSocial Portuguesa. Declare quepeloconhecimentoque tcnho sobre as infomaq&s dadasno presenterequaimento, alas siio verdadeiras ecompletasecomprometo-mea avisar o Cmtro Nacionalde Pens6es de qualqua alteraqlo que posse afectar o direito hs prest@es. I hereby apply for Ponuguese Disability or Old Age bcnefiu. I declare thal, to be best of my knowledge, the information provided in this application is accurate and complete and I undenake to inform the National Pension Centre in Portugal of any changes which may affect my entitlement to benefits. Par les prkentu, je demande des prestations portugaises d'invaliditbou de vieillesse. Je dbclare qu'8 ma connaissance. les renseignemenu foumis dans la prCsenre demande son1 vdridiques et compleu et je m'engage ?I aviser le Centre National des Pensions du Portugal de tout changement pouvant affecter le droit aux prestations. 2 - Data / Date / Date Assinatura / Sinnature / Sipnature DECLARA~KO DA TESTEMUNHA SE 0 REQUERENTE ASSINOU POR ME10 DE (X) DECLARATION OF WITNESS WHEN APPLICANT SIGNS BY MARK (X) D$CLARATION DU TBMOIN SI LE REQU$RANTSICNE D'UNE CROIX (X) NOTA: A assinatura feik por meio deuma cruz (x) s6 C vslida quando esta declara~Io6 assinada por uma testanunha que conhea o requamte. NOTE: Signature by mark (x) is aoceptable if a witness who knows the applicant signs this declaration. A NOTER: La signature au moyen d'une croix (x) n'est valide que si un ttmoin qui comait le nqutrant s i p ceae &laration. I Li o wnteddo do pruente pcdido ao requerente que panceu compreend2-loe assinou com urna (x). I have read the contenu of this application to Ihe applicant who appeared to understand them and who made his or her mark (x). J'ai lu le contenu de la presente demande au requ&ant qui a sembl6 le comprcndre et qui a sign6 d'lme croix (x). - 6. - - ASSINATURA DA TESTEMUNHA (em leaa conente) SIGNATURE OF WITNESS (do not print) SIGNATURE DU TEMOLN(ne pas signer en lettre moul6es) Data Date Date ENDEREGO DA TESTEMUNHA ADRESS OF WITNESS ADRESS DU TEMOIN NP de Telefone Telephone no NP de telephone PARA US0 EXCLUSIVO DOS SERViCOS I FOR OFFICE USE ONLY I A L'USAGE EXCLUSIF DU BUREAU Para ser compleudo pcla instituigo competmte do Canad4 To be completed by the competent institution in Canada A 2- compltt6 par I'ititution compCtentc du Canada Cmifiw que os elemcntos de idmtifica@o contidos no presente formulMo foram retindos dos documentos oficiais apresmudos pel0 requercnte. I hereby certify that the vital statistics data contained on this form are taken from official documents provided by the applicant. Par les prtsentu, j'atteste que les donnCcs pcrsonnelles inscrites sur ce formulaire ont Cd tirtes des documents officiels foumis p le requkant. r Dia Day Jour Data de entrada do nquerimento Date application receivcd Date de rhplion ce la demande 1 M2s Ano Month Year Mois Ann& IdData / Date/ Date / I Carimbo ou selo branw S m p or blank seal T i b e ou stew sec L J Assinatura / Signature/ Signature b Canada / Portugal Agreement Documents and/or information required to support your application [CDN - P 1] for a Portuguese Old Age and/or Disability Pension Complete the attached form: • Canadian Residence [ISP 5013] [only if you have less than 10 years (for an Old Age pension) or 5 years (for a Disability pension) of contributions to the Canada Pension Plan] Original or certified documents to be submitted: • Birth certificate or Cédula Pessoal • An official Portuguese document indicating your full name, birth and birthplace (such as: birth or baptismal certificate, Cédula Pessoal, identity card, or passport) • Proof of the dates of your entry(ies) to Canada and departure(s) from Canada (such as: Immigration 1000, passport, visa, ship or airline tickets, etc.) [only if you have less than 10 years (for an Old Age pension) or 5 years (for a Disability pension) of contributions to the Canada Pension Plan] • Medical report if you require the constant assistance of another person. If this is the case, you must also complete section 4 of the application form. A copy of the following document must be submitted: • Taxpayer card (if available) IMPORTANT: If you have already submitted any of the documents required when you applied for a Canada Pension Plan or Old Age Security benefit, you do not need to resubmit them. Human Resources Development Canada Développement des ressources humaines Canada Protected when completed - B Personal Information Bank HRDC PPU 175 CANADIAN RESIDENCE Canadian Social Insurance Number Mr. Mrs. Ms. Miss First Name and Initial Last Name The following information is required to support your application for benefits under a social security agreement. If required, please provide additional information on a separate sheet of paper. 1. If you were born outside of Canada, please provide us with the following information: • Date of arrival in Canada: • Place of arrival in Canada: 2. List all the places where you have lived in Canada after the age of 18 and provide proof of all your entries and departures (immigration 1000, complete passport, airline tickets, etc.): From (Year/Month/Day) To (Year/Month/Day) City Province/Territory 3. List all absences from Canada, which were longer than six months, during your Canadian residence listed in number 2 above: Departure (Year/Month/Day) Return (Year/Month/Day) Destination (Ce formulaire est disponible en français - ISP 5013 F) HRDC ISP5013 (2005-08-002) E Page 1 of 2 Reason Canadian Social Insurance Number 4. Please give us the names, addresses and telephone numbers of at least two people, not related to you by blood or marriage, who can confirm your Canadian residence: Address Name City Telephone Number ( ) - ( ) - DECLARATION OF APPLICANT I declare that this information is true and complete. (It is an offence to make a misleading statement) Signature: X Telephone number: Date: ( HRDC ISP5013 (2005-08-002) E ) Year - Page 2 of 2 Month Day
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